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Heart Arrhythmias&Device Therapy (Drs Baranowski&Wilkoff 03 21 14)

Friday, March 21, 2014 - Noon


Arrhythmias (irregular or abnormal heart beats) are very common and are often a mere annoyance. However, they can also be responsible for life-threatening medical emergencies that may result in cardiac arrest and sudden death. There are several treatment options for this condition, one of which is often with devices such as a pacemaker or defibrillator. Bruce Wilkoff, MD and Bryan Baranowski, MD answer your questions about arrhythmias and device therapy.

More Information

Implantable Defibrillator (ICD)

dlindley: I have AFIB as well as HCM. I have a pacemaker/ICD placed April 2012. On December 24th of 2013 I went into AFIB and was shocked nine times by my ICD with rhythm restored after the ninth shock. This is the first time the ICD has gone off even though I had experienced AFIB several times since the ICD was placed. The other AFIB events were controlled by additional Norpace pills. After the last AFIB event my Doctors changed my Norpace to 200 mg twice per day. In addition I take 20 MG of Atenolol twice per day. You should also know that I had rotator cuff surgery on December 18 ahead of the 12/24 AFIB event and was on pain medicine at that time. My question has to do with the chance of future AFIB events resulting in the ICD going off to control the heart rhythm. The additional Norpace and Atenolol is well tolerated with no additional AFIB events since changing the medication. I have not had a cardio version since 10/2011 when I began the Norpace medication.

Bryan_Baranowski,_MD: You should not have to receive shocks for afib. Changing your antiarrhythmic medications to limit further afib episodes is a good first approach, however I am concerned you will still be at risk for afib events. In many instances, there are opportunities to change the programming on your device to limit the likelihood of inappropriate and unnecessary shocks for afib.

Az1435t: I have had an ICD single lead since Nov. 2012 after being diagnosed with CPVT at CC. I recently started Tikosyn to better control Afib/Flutter (after 3 ablations). In the past month my left arm has become achy and then numb whenever I try to more fully open my chest ( heart openers in yoga pose) or sometime when I just lie flat on my back. My ICD is quite superficial because I am thin (112 pound, 5'10") and it actually moved after it was implanted so it sits partially on my upper arm. Is it possible that pressure from the ICD could be putting pressure on nerves that is causing the numbness? Any suggestion on how to handle? My EP is reluctant to try to move the device due to infection risk. Thanks for your thoughts.

Bryan_Baranowski,_MD: It is possible for the device to be responsible for your symptoms but unlikely. We share your doctors concerns about removing the device unless we are sure it will help you. An evaluation by an neurologist may be helpful to see if your device is responsible for your neurological symptoms.

Mizzou: I have a defibrillator implanted 10/13 have had a Tachycardia upper chamber jolt, three times within 15 minutes. I am now on Amiodarone Hcl 200mg. I am so panicked about this that I want to see if I can go another way instead of being shocked. Have a wonderful Cardiologist and mentioned that if this kept up they could do an ablation thought the groin area. My health is good otherwise, but the panic attacks I am having I don't think I can do this. This medication does it help, please help me I am really scared and have trouble sleeping or coping with daily chores. I exercise at my gym twice a week and I am normally very active. Can defibrillators be removed can I do something to help prevent these attacks, Thank you.

Bruce_Wilkoff,_MD: How your situation should be managed is highly dependent on the reason that the defibrillator was initially implanted and the reason that you got these particular shocks. Your experience has been traumatic but does not have to continue this way. Over time with good control of your heart rhythm you should be able to manage life with the defibrillator much better. Your care should be a combination of managing your heart rhythms and also helping you to cope with the defibrillation therapy. Defibrillators can at times be removed but if they were put in for a good reason it is unusual to remove them. You might consider a second opinion before you choose to do any particular approach to your situation.

ICD Leads

goodoldan: Dr. Wilkoff, I received a St. Jude Riata ST lead in 2008 when my first ICD was implanted. These leads have since been placed under an FDA "advisory". I just had my generator replaced last month (battery at ERI) and fluoroscopy at that time showed no lead externalization. There is currently no other apparent indication (impedance change, etc.) of any other issue with the lead. I'm concerned, however, that this lead may fail sooner than later, and since I'm only 60 I'd like to think I'll be around for a while yet. Given the state of the art relative to lead extraction, should I insist that this lead be replaced at my next generator change (I read that lead extraction gets more difficult over time)... or is that just taking an unnecessary risk? Of course, I'd come see you at Cleveland Clinic for the procedure! ;)

Bruce_Wilkoff,_MD: First of all I think it was the right decision to not replace the lead at your recent generator change. Although it does get more difficult to takes leads out as the scar has more time to progress, the changes are small over time. In five - seven years, we will know a lot more about how the Riata lead is doing and we will know more about how you are doing and then we can relook at this - however at this time, you made a good decision for your recent procedure. It is important that you continue to have regular defibrillator follow up and this would be true if you had a Riata lead or any lead as any lead can fail over time. However, regular follow up reduces the risk that this causes any harm.


coljake1: I have afib. Age 85. Is a pacemaker ever recommended without also doing an AV node ablation? Thank you.

Bruce_Wilkoff,_MD: Hi, treatment of AFib sometimes requires a pacemaker and sometimes requires AV node ablation but sometimes requires neither, one or the other. So at age 85 it may be that your heart rate is going too fast at times but when they try to treat with medications it will go too slow. Under these circumstances a pacemaker is a good idea as it will allow more medication to control the fast heart rhythms without getting slow heart rhythms. If the medication is not effective enough then the ablation of AV node would be appropriate. Neither of these interventions protects you from the risk of stroke which usually requires anti-coagulation.

Bala: If you have atrial fibrillation, when are you a candidate for pacemaker and AV node procedure?

Bruce_Wilkoff,_MD: Patients with Afib have a poorly controlled heart rate. Sometimes the heart rate is too fast and sometimes it can be too slow. A pacemaker would keep the heart from going too slow and an AV node ablation would keep the heart from going too fast. Depending on the characteristics of the heart rate at rest and with exercise one or both of these procedures can be done. Neither the pacemaker nor the ablation protects you from strokes but requires anti-coagulation.

Pacemaker Mediated Tachycardia (PMT)

dsmu: I have an AV node that reverses direction. I have an ICD. I get many episodes or arrhythmias they say are PMT, Pacemaker mediated Tachycardia. Should I have the AV node disabled?

Bruce_Wilkoff,_MD: The AV node normally conducts the message from the atrium (upper chamber) down to the ventricular (lower chamber) but it also usually will conduct from the bottom to the top, as you are describing. This is normal. There is a way to adjust the ICD to prevent these PMT episodes under most conditions. Sometimes the message comes back too slowly through the AV node and it is necessary to do an ablation to prevent that from happening. However this is quite rare to need this.

dsmu: Do I need to ablate my AV node to prevent PMT?

Bryan_Baranowski,_MD: Not necessarily - sometimes programming changes through the device can correct this. PMT = pacemaker mediated tachycardia.

Implantable Defibrillators (ICD)

goodoldan: Dr Wilkoff, the patient literature I see from the manufacturers of ICD devices pretty much all says that family members, caregivers and the like cannot receive a shock by touching a patient when the ICD delivers therapy. It even goes so far as to say that should a person with an ICD receive a shock during sexual activity, their partner may experience only a "tingling sensation". My wife and I were in that situation when my ICD delivered a 36J shock a few years ago... and she experienced far more than a "tingle". Her description of the event sounded very similar to what I experienced... a painful jolt. I cannot know exactly what she experienced... but it was severe enough that she has refused any such activity ever since. I have read reports of similar experiences from other ICD recipients... it seems like these are more than random, isolated incidents. Is the information from the manufacturers regarding the safety of others around ICD patients incorrect?

Bruce_Wilkoff,_MD: This is a very important question. People often confuse the sensation of a shock, meaning an electrical sensation, and the contraction of muscles. So the electricity form the defibrillator is designed to cause the entire heart muscle to contract at once. But it also can make the chest wall muscles, the abdominal wall muscles, back and arm and leg muscles contract. From the data that we have collected in the past, no more than a very small amount of energy is actually transmitted but the muscle contraction can be very dramatic. It is the muscle contraction which is not dangerous, that people find surprising and uncomfortable at times. In addition, the surprise of an unexpected jerking of the muscles often is frightening. Just like when somebody sneaks up behind you and taps you on the shoulder, you may jump and even may say it hurts because of the surprise. I am sorry that this has caused problems with you and your wife but there is absolutely no risk to her or you, or anyone else from the shocks.

Premature Atrial Contractions (PACs)

RMusgrave: What can be done for benign PACs if anything or is it best to do nothing? Are there any studies showing that people with heart arrhythmias, such as PACs, have a shorter life span than those with no arrhythmias?

Bryan_Baranowski,_MD: If the PACs are completely benign and not causing any symptoms, generally they are left alone. In rare cases when you are having a very large burden of PACs to the point of causing sustained episodes of tachycardia, there can be an associated weakening of the heart muscle due to fatigue – this is a reversible process. In the absence of symptoms or heart muscle fatigue we generally leave the PACs alone. There are no studies showing that the treatment of benign PACs changes life expectancy.

Atrial Fibrillation (Afib) Causes

Joan1122: Can you please help me with the connection between sleep apnea and afib ablation. I got my first ablation last fall and the heartbeat was normal for three months, then I got a new kind of flutter and had to go the ER to slow my heart down with IV diltiazem. Now my heartbeat does not usually speed up but I have diltiazem pills in case it does. I do have irregular heartbeats now. But my main question is, right before I got the irregular heartbeats again, I had two bad nights of sleep apnea. Is there a direct connection between that episode and the ablation failure? Also, does a second ablation need to be performed by the doctor who performed the first. Thanks so much!

Bryan_Baranowski,_MD: There is a relationship between obstructive sleep apnea (OSA) and atrial fibrillation (afib). During apnea episodes your oxygen level can go down, causing a stress on the heart, increasing irritability and leading to afib events. However there are many people with OSA who never get afib – so there must be an underlying cardiovascular predisposition to afib, which OSA can exacerbate. Treating OSA can help limit the episodes of afib but it will not eliminate it entirely. The second ablation, if you need one, does not have to be performed by the original doctor.

RogB: Since 2010 I've had paroxysmal afib about every ten days to two weeks. Currently on Sotalol 120mg x2. It seems as if something "builds up" (sensation in upper chest as if heart is rising) which precedes afib and then, once having gone through an episode up to 24 hrs, the heart kind of "resets". Only get episodes after going to bed, especially lying on my side. Sometimes a liquid antacid will suppress an episode. Can this be vagally mediated afib and if so what can be done short of ablation?

Bryan_Baranowski,_MD: It certainly sounds like there could be a vagal contributing factor to your afib episodes. We do not specifically alter our management approach in this setting. It sounds as if on sotalol you continue to have episodes of afib – if this is significantly impairing your quality of life then altering your medications or an ablation may be the next best step. Ablation can be quite helpful for vagal mediated afib as we indirectly ablate and disrupt the vagal nerve input into the heart.

hoagie0013: I was diagnosed with a-fib ten yrs. ago. Through the yrs. I have had three ablations. The last being one yr. ago. I kept telling electrophysiologist that I felt stomach issues were involved with the a-fib. This seemed to be dismissed and I was told I needed "touch up" ablations. finally I decided that I was going to have stomach scoped after reading about and seeing DR.OZ talk about how h pylori can contribute to arrhythmias. Scoped and biopsy revealed I had h pylori. Gastro prescribed two antibiotics which I took for two weeks. Have not gone into a-fib since antibiotics were taken. Doctors in Italy have found a connection with h pylori and a-fib. All clinics in Italy they screen for h pylori when anyone comes to them with arrhythmias. why isn't this done here.

Bryan_Baranowski,_MD: There are case reports of this connection but the cause and effect link has not been confirmed medically. This is not part of the recommendations at this time to check for h pylori as part of a treatment approach to treat atrial fibrillation. Cases such as yours are more the exception than the rule.

Atrial Fibrillation and Thyroid

Pascal8: Have had AFib for years. On Metoprolol plus Warfarin now. Found that the thyroid affects AF terribly and can verify that when I was on higher dose of Levothyroxin I not only had periodic episodes of severe nausea, but also affected the digestive tract and then the AF got worse. What do you know about the association, and, what is the optimal TSH level to most benefit AFib?

Bryan_Baranowski,_MD: Over medication with thyroid replacement can create a state of hyperthyroidism or metabolic over-activity. This can lead to more atrial fib events or if you are persistently in afib can worsen heart rate while in afib. Keeping your TSH in normal therapeutic range is ideal.

Atrial Fibrillation Ablation

Pensmith: I had a Maze procedure done at CC in 2001, no afib until three years ago; now I go in and out of afib. My (local) electrophysiologist is considering an ablation but feels that the Maze procedure will make it more time-consuming so is considering drugs instead. What is your opinion on both?

Bryan_Baranowski,_MD: Assuming your current episodes of afib are symptomatic, suppressing your afib with meds or an ablation procedure is reasonable. Both procedures can be utilized – there is no defined optimal strategy. Medications limit your exposure to the acute complications of an invasive approach but medications may carry side effects and have limited long term success. Ablation may have longer durability but exposes you to the upfront risks of an invasive procedure. These are complex decisions that usually require sitting down in a clinical setting and discussing all the risks and benefits.

Plantman: I have heard that there is a new procedure coming soon that will dramatically cut down the time and accuracy of the pulmonary vein ablation for atrial fibrillation or PVAI. Is this true? If true how far in the future? Is A-fib progressive? Do the medications such as amiodarone gradually get less effective? What is the relation of A-fib to GERTS? What are the lasting effects of a successful PVAI ? Do you think PVAI is a good solution for a man of 73 years who is fibrillating about 25% of the time with some periods of three to four in sinus rhythm and one to two days in A-fib? Can the use of Xarelto be bad for a person with a slightly enlarged liver? Thank you.

Bryan_Baranowski,_MD: Afib is progressive. It is true that all afib medications become less effective with time. There are several newer strategies coming such as ablation lasso along with new ways of targeting afib. With all new technologies and approaches, there are usually a lot of excitement regarding their introduction but the long term benefit of the strategies are yet to be proven. At a large academic institution such as ours we are usually on the fore front of these new technologies.

The ablation approach in the setting of a patient such as paroxysmal afib (comes and goes) is typically done with the intent of achieving cure. Whether it is right for you depends on a lot of factors and it is a complex decision which requires a thorough evaluation.

So long as your liver function is normal, I am not aware of a contraindication of using Xarelto.

Weathsn: I am a 74 year old female that developed paroxysmal AFib two year ago. All of my adult life I have had a slow resting heart rate of 45 to 60. I am in average health with mild to moderate valvular heart disease. I had lots of side effects from antiarrhythmic drugs - very low heart rate, etc. I am on the anticoagulant - Xarelto 15mg. I have been in Afib for four weeks with a heart rate in the 80 & 90's. I had a steroid injection about three weeks ago and I think it could have set if off. Medication that I presently take, Benicar 40 mg, Chlorthalidone 25 mg, inspra 50 mg 2 x daily, Lipitor 20 mg, synthroid 75 mg. Should I consider catheter ablation and possible a pacemaker?

Bryan_Baranowski,_MD: Ablating your AV node and putting in a pacemaker is usually a strategy of last resort for those who are stuck in permanent afib and have very high heart rates while in afib despite appropriate medical therapy. Your description is not consistent with this presentation. If you tend to not feel as well in afib episodes then an ablation of the pulmonary veins to target the afib may be a more reasonable approach. If you are largely unaware of your afib episodes then your current management strategy may be sufficient.

SPITZEREDR: I have persistent a -fib. My stress test showed no heart valve problem or heart disease. I have undergone electrical cardioversion twice and have reverted to a-fib within a short time afterwards. I am taking Pradaxa 175mg and Flecainde 100mg twice a day and Diltiazem 120 ER once a day. I would have never known I had A-fib, but I insisted on getting an EKG and a chest x-ray as part of my annual physical two years ago. My electrophysiologist says that I can probably get along and manage this condition and says that an ablation probably isn't worth this risks involved and the prognosis for success would be around 50%. I have always had normal blood pressure and cholesterol ranges. I would like to know what another cardiologist could recommend and am planning to see a Dr. who is considered an expert in using mapping to do ablations. My current Dr. says they don't have that much information about it.

Bryan_Baranowski,_MD: We typically only pursue an ablation approach to improve your quality of life. If we are fairly certain your atrial fibrillation is not resulting in any symptoms – then we would agree with your local cardiologist that an ablation procedure is probably not justified.

Ablating someone with persistent asymptomatic afib has never medically been proven to improve life expectancy or reduce complications related to afib (stroke risk).

oldgolferguy: Have had Afib for decades with a variety of meds over the years. Pacemaker since 1997 after passing out. Now age 75. Currently taking propranolol, amiodarone, pradaxa and fenofibrate. Have been talking to EP doc for years about ablation. He is now recommending cryo-ablation in order to reduce meds and avoid their possible side effects; however, the latter are not detectable yet through regular blood, urine, and breathing tests. Another EP doc also recommends ablation, but would use the older RF technique.; he believes the cryo technique, while promising, has not yet developed a long enough track record. Two questions: Should I have an ablation at this time, while continuing to monitor for medication side effects? If ablation is indicated, which technique is preferred at this time, cryo or RF heating? Thank you.

Bryan_Baranowski,_MD: The potential benefit of ablation would be to eliminate the ongoing need for amiodarone which over time can have toxicity. The longer people are on amiodarone the higher risk for toxicity over time. We typically only use this medicine if absolutely necessary because the toxicity that it can create can have permanent effect on your thyroid, lungs and liver.

Ablation may be reasonable. There are no head to head trials of cryo vs. RF. Both procedures are performed here. We are currently in the process of comparing our outcomes with one strategy vs. another – but at this time have not any definitive information.

jennyverburgt: My husband had Afib procedure in December of 2013, and now feels worse than before, is this normal, our Doctor is not concerned?

Bryan_Baranowski,_MD: It is not normal to feel worse after a procedure and it should prompt further investigation. There may be ongoing arrhythmia issues or other mechanical complications from the procedure that may be uncovered and addressed that may make him feel better. It would depend on his symptoms in this case. We would be happy to see you.

Poppa: After working as a firefighter with A-fib for four years, I retired at the age of 65. Now at the age of 66 I was wondering, what are the odds of a successful ablation? I have never received a second opinion. Thank You.

Bryan_Baranowski,_MD: Success rate of afib ablation depends on a variety of factors - including - atrial fibrillation pattern (Paroxysmal vs. persistent); the duration of your afib diagnosis; and very importantly the size of the top chamber of your heart, atrium. Ideal candidates who have not had atrial fibrillation for very long, normal heart chamber size with paroxysmal afib, the success rate is about 75%. This rate can increase up to 90% if up to two ablation procedures are pursued.

Atrial Fibrillation – Medication Management

qtipgram: I was very recently hospitalized to change from metoprolol 25 mg 2 x daily , to sotalol 120 mg 2 x daily. How long will this medicine be successful or will I be looking at having a device implanted in the future? I am a 74 yr old female. Thank you.

Bruce_Wilkoff,_MD: It appears from your question that you might have a primary diagnosis of Afib. However, sotolol can also be used for ventricular arrhythmias. Sotolol is effective in some people and not others. Sometimes for many years and sometimes for only weeks or months. The alternatives to sotolol are not only a pacemaker or defibrillator but could be other medications or an ablation. I would be happy for the moment that my rhythm is under control and then worry about the next step when it occurs.

WR: I am a 73 year old male diagnosed with atrial fibrillation. After discontinuing pipe smoking & nightly glass of wine, I have not had an episode of AFib in seven months. I currently take Toprol Xl 25 mg and Eliquis 5mg daily. Is the continuation of Eliquis 5mg necessary? Thank you!

Bryan_Baranowski,_MD: The need for continuing anticoagulation depends on a variety of factors. After your first episode despite from refraining from smoking and drinking wine, you remain at risk for afib. Typically we like to see patients go a full year without an episode of afib before stopping it although if you have additional risk factors for stroke, it may be continued for longer than this.

Preciouscar: Does Afib last for extended time or can it go in and out second by minute? I am 73 with Paroxysmal afib; heart rate well controlled; is there a pill I can pop when I have a problem? I have been seen at Cleveland. How good is the handheld Heart Rhythm Monitor by CardioComm Solutions, Inc.?

Bryan_Baranowski,_MD: Usually earlier stages of afib start in a paroxysmal manner - short bursts that come and go. Later stages or advanced stages of afib tend to be more persistent or long lasting. There are medicines that can be used as a pill in pocket to convert afib back to regular normal rhythm. This strategy only makes sense when the episodes are relatively infrequent and resistant to going back to rhythm on their own. I am not familiar with this particular monitor.

Medical Management – Anticoagulation

Wx Doc: My questions are: What are latest study results on bleeding using Apixaban and Rivaroxaban? Since my creatinine number may be just a tad high I am also a bit concerned about Renal Metabolism of these drugs. I have taken note that while 80% of the metabolism of Dabigatran is in the kidney (one horseshoe in my case) only 25% of Rivaroxaban is metabolized in the kidney. Would this drug be better for the kidney. My second question is about the Chads algorithm. I believe that the only two factors in my case are congestive heart disease and hypertension. I just turned 74 this month, do not have diabetes, and again my TIA was 11 years ago. If I am correct this would give me a score of two on the Chads scale. I believe that an antiplatelet monotherapy of clopidogrel alone would be satisfactory in my case. Am I incorrect on this point? Thank you for considering my case. I look forward to your recommendations. Sincerely, Charles.

Bruce_Wilkoff,_MD: Kidney function is not a significant problem unless very severely depressed for apixaban and rivaroxaban. Dabigatran would not be a good idea. Your CHADS two score is higher than you think, possibly five. Heart failure, hypertension, TIA/stroke, and age. At 74 you are just one year from 75 and TIAs count for a score of two. Bottom line your risk of having a stroke without anti-coagulation is significant and unless you have had problems with an anti-coagulant it is likely that you should be taking the medication. If your situation changes such as changes in your kidney function, or bleeding than this can be reconsidered. Anti-platelet therapy is not adequate for your situation.

Atrial Fibrillation Treatment with Blood Clot

Ell: Best way to get out of irregular beat, afib or flutter. Dr wants to do TEE and shock. Also ablation was suggested. TEE scheduled for next week. Why not try pills (in hospital monitoring) or IV injection first? Irregular beat has been consistently irregular for several months changing from pac, pvc, atrial flutter and afib. Patient on Xarelto as of two weeks. Thank you.

Bryan_Baranowski,_MD: No matter how we get the patient back to normal rhythm - shock, meds or ablation - we have to first be sure there is no blood clot in the top chamber of the heart or atrium. If there is , when the heart is changed from a quivering state to a squeezing state, the clot could dislodge and cause a stroke. To prevent stroke, we typically assess with a TEE or treat for at least two weeks with full dose anticoagulation.

EJRY57: I have persistent afib which I've had treated medically over the last 15 yrs. and then three yrs. ago with an unsuccessful RF ablation...I've been in afib since and have been on Pradaxa for anti-coagulation. I was scheduled to have a Cryo-ablation this week but the Dr. found a clot in the left atrial appendage and I am told open heart surgery to remove the clot and receive surgical ablation (Maze) is my best option to proceed. I have no other issues (no heart disease or valve problems) and wondered if there are less invasion options available to me.

Bryan_Baranowski,_MD: If the clot can be dissolved using blood thinning medicines and sometimes that means switching back to Coumadin, then this could potentially open up the option to proceed with a second ablation procedure. Dissolving blood clot can take up to three months. And will require a repeat TEE to confirm.

NanaLiz: I have a calcified blood clot in my left atrial appendage due to persistent Atrial Fibrillation (but I've been on Pradaxa or Coumadin at therapeutic levels for three years). What's my best course of action?

Bryan_Baranowski,_MD: It depends on your goal of care. For minimizing your stroke risk it may be nothing more than continuing full dose anticoagulation. If you need a procedure to address symptomatic atrial fibrillation, typically percutaneous approaches are deferred due to the risk of embolizing the calcified thrombus and a surgical approach such as Maze procedure with ligating the appendage may be helpful.

Atrial Fibrillation and Exercise

David0646: I am 67 years old. I have been running for 20+ years averaging 30 to 35 miles per week. After wearing a “CardioNet” monitor for two weeks, I have been diagnosed as having afib. I have a running watch with a heart monitor. For the past five to ten years, when I started my daily run, my heart rate would jump to 150 to 165 and after a ½ to one mile stabilize at about 135 to 145. I thought it was the watch. Now I know better. I know that there a multiple treatment options. I have tried digoxin. With a resting heart rate around 50, this did not work.

Bryan_Baranowski,_MD: There is a correlation to endurance athletics and atrial fibrillation. Digoxin is usually only successful in treating heart rate in patients who are sedentary. There are likely better treatment options for you that could be determine with an evaluation. I am the EP representative for the sports cardiology center that is being started at Cleveland Clinic and I would be happy to see you for an evaluation.

Atrial Flutter

faride: Hi, I have an atrial flutter. I have been taking metoprolol and xarelto since last November that I was in emergency with strong arrhythmia. My Dr. (electrophyisician) now told me to suspend both medicines and wait for the arrhythmia to come again to do an ablation. Do you think I'm taking a risk for stroke?

Bryan_Baranowski,_MD: We would need more information to determine stroke risk. This is usually tied to additional medical comorbidities that you may have. We use the CHADs score to help determine this. We would be happy to see you in person to review your risk of stroke off anticoagulation.

Supraventricular Tachycardia

Chuckarc: My mom has an aortic aneurysm 5.3...she gets sudden bouts of tachycardia (158) that lasts a few hours and subsides after she takes extra tenormin and a clonopin. What is this called and why is it happening?

Bryan_Baranowski,_MD: A sudden onset of tachycardia is usually referred to paroxysmal supraventricular tachycardia or PSVT – it typically implies that there is an extra electrical wire or an area of irritability in the heart that are responsible for a sudden onset of a fast heart rhythm. These rhythms also tend to terminate suddenly. However there are lots of other means by which you can have a fast heart rate. Further evaluation is needed with cardiac event monitoring to understand your mother’s rhythm and the mechanism for the tachycardia.

Eag: With tests years ago, wife shows no blockage, minor mv prolapse, left bundle branch block. Recently sees two cardiologists, one and EP. Daily has skipped beats, palpitations randomly. Frequently dizzy, short of breath, tired with little exertion. Often gripping pains in back leads to tight/squeezing chest pain lasting 30 mins - two hours, heart races to 190 bpm lasting 30-45 mins up to two-three times a day. First doctor thinks SVT. Has her wear cardionet event monitor for three weeks, thinks AFib. Prescribes flecainide. Two days into treatment feels worse than ever. Nurse says try for full week. Feels even worse/ discontinues. Two weeks off, feels better but not normal, symptoms enhanced. Sees EP, reviews record, says maybe not AFib after all, maybe SVT. Prescribed Acebutolol/Sectral, however afraid/distrust will have terrible reaction like flecainide. Is this beta blocker safe? Petite lady, normal bp 105/70. Concern over too low bpm and lung constriction. Any idea what next tests would give clearer diagnosis?

Bryan_Baranowski,_MD: It would be very difficult to comment on this without seeing the cardio-net strips due to the complexity of the case involved. A second opinion is the only option to determine what is best after reviewing the cardiac event monitoring.

lls1973: I have SVT and have had two attempted ablations (over the past three and a half years), which couldn't be performed due to failed attempts to induce the arrhythmia during the procedures. My symptoms are so bad (except when I'm in an OR, trying to get it fixed, of course), that I'm on 100 mg of Flecainide twice per day. It does help control about 75% of my symptoms, but I am only 41 and in excellent health otherwise, and don't want to be on this medication for the rest of my life. My cardiologist does not believe I should keep having ablation attempts, but I have heard/read that it sometimes takes multiple attempts to find the trigger spot in the heart. I also had a loop monitor for a year (it's out now), which did help pinpoint the general area. My last ablation attempt was two years ago. My question is: what is the average number of attempts you would do for someone my age with this condition? Should I keep trying? Thank you, Laurie.

Bryan_Baranowski,_MD: Your particular scenario is not uncommon. We are most likely dealing with an arrhythmia that is irritability within the heart. This irritability can be very unpredictable. In the EP lab, the area can only be identified and ablated if it is actively misfiring or irritable. Most of the time if not spontaneous irritable, we will use a variety of medications to provoke the misfiring. It would not be unreasonable to attempt a third ablation, however, if you are not spontaneously misfiring at the time of the procedure, we will try these medicines first to see if the arrhythmia is inducible before placing catheters in the heart and exposing to the risks of the procedure. We would need to evaluate you.

AV nodal reentrant tachycardia (AVNRT)

guest: My friend’s 15 year old daughter has AVNRT – an ablation has been recommended locally because she has symptoms as a high school swimmer. Are there any concerns she should ask her EP doctor? Is general anesthesia typically used in this type of case? What type of success rates should she expect?

Bryan_Baranowski,_MD: Assuming it is AVNRT and the arrhythmias are recurrent, ablation typically is the treatment that is recommended. Medications are unlikely to be 100% successful. The biggest complication or risk for an ablation for AVNRT is damaging not only the extra wire but the main wire connecting the top and bottom chambers of the heart. In such a circumstance the patient will no longer have AVNRT but may need a pacemaker. This is a rare complication that occurs typically less than 1% but having the procedure done at a center that does many cases of this will lower the risk sooner.

Ventricular Tachycardia

BBAR1: Is it safe/wise to have a treadmill stress test if you have idiopathic ventricular tachycardia and have one stent?

Bryan_Baranowski,_MD: Exercising in the hospital, where there are medically trained personnel available to deal with the arrhythmia should it occur, is probably the safest place to evaluate exercise. This would make your cardiologist more comfortable with you exerting yourself on an everyday basis.

Dsm08: Prior to having two cardiac ablations, I was having an extremely large amount of PVCs and NSVT, hardly any bigeminy. About six months after my second ablation I started having bigeminy/trigeminy. For the last the last 22 months now I have bigeminy, daily for hours on end, I wish I could go an hour without it but it doesn't happen. I also still have the NSVT and PACs. My question is, what kind of help is there? I am just told it won't hurt me, but I feel every bit of it and it is not fun. I get weird blood pressure readings while I have the bigeminy. I don't see how this doesn't have an effect on the body. I am on atenolol which does not help. I have tried anti-anxiety meds but can't tolerate them due to fatigue. Any insight would be greatly appreciated.

Bryan_Baranowski,_MD: We usually attempt to ablate and suppress PVCs for 1) they cause symptoms or 2) there is an associated weakening of heart muscle function due to all the extra bests. It seems that the first indication may apply to you and this is probably why ablation was attempted twice prior. Ablation procedures can be unsuccessful for a variety of reasons. Usually it is due to the indication from which the PVC is arising and difficulty in reaching this position with a catheter. We can better assess the likelihood of success of third ablation after seeing your prior EP reports and gaining a better understanding of the difficulties encountered and morphology of rhythm. Medical therapy of PVCs usually result in suboptimal results but if a third ablation is not an option there are things we could try.

kahuna8: I have a recent diagnosis of "Polymorphic Ventricular Tachycardia" based on a single, standard stress test. I also have aortic valve stenosis(mid-severe) range. Age 77, otherwise very good overall health. What, if any, additional tests would you suggest as to the PMVT. THANK you.

Bryan_Baranowski,_MD: PMVT can have several reversible causes. In your particular scenario would be the most common and concerning. Depending on the results of the stress test, a heart cath may need to be pursued. Other potential causes for PMVT could be determined after reviewing your other medical history including your EKG and current medications. If a reversible cause is not found, you may benefit from placement of a defibrillator. This can be a complex and potentially life threatening arrhythmia - we would recommend an evaluation at a center such as ours.

Symptom - Dizziness and Fainting

xdwl: Hello doctor, I am 56 year old female with HCM (post- septal myectomy). I had taken Metoprolol Succinate 47.5mg/day for eight months as basic treatment for HCM. My pulse was around 45-55 bpm and occasionally felt mild lightheadedness. My holter showed: sinus rhythm, average heart rate was 48 bpm, Degree-1 AV block, the lowest heart rate was 40 bpm (happened in the afternoon with no symptoms). BP normal. However, one month ago, I had one FAINT when I was sitting at a sofa. It lasted for about five seconds. I checked my pulse immediately after recovery, it was 50 and regular. I have cut down Metoprolol Succinate to 23.75mg/day. My pulse is 53 and I feel fine now. I have no risks of CHD. I would like to ask, with fainting history, is it safe for me to keep the low dose 23.75mg/day? And can I gradually increase the dose back up to 47.5mg/day if I am stable? Thank you very much!

Bruce_Wilkoff,_MD: There are many potential reasons for fainting or near fainting in patients with HCM. A slow heart rate would have to be very slow to cause those symptoms, but it is possible. Other potential causes include ongoing problems from the HCM or rapid heart rhythms. The rapid heart rhythms could be atrial or ventricular. Since we don't have your heart rhythm during the light-headed spell, it is not possible to say whether it is safe for you to take the beta blocker. Perhaps you should have an event monitor that would allow you to record your heart rhythm at the moment of your symptoms. It is possible that you need a pacemaker, or even possible an implantable defibrillator. For now, I would not stop the beta blocker but still get the event recorder.


Bigbadtom: I am a male, 70 years old. I had a major MI in 2000 and have been taking beta blockers (Toprol) until January 1, 2014, when I developed Bradycardia (slow pulse). I'm off beta blockers but my doctor wants me back on along with a pacemaker as backup. Is this the standard practice? Won't the beta blockers slow down my heart even more?

Bryan_Baranowski,_MD: Beta blocker therapy has been shown to reduce risk of a second MI and that is probably why your local cardiologists are keen to continue. The side effect of beta blockers is slow heart rate. If this slow heart rate is slow enough to cause symptoms – dizziness and lightheadedness – in certain circumstances, will place a pacemaker.

Arrhythmia after Surgery

xdwl: Hi, Doctor. I am with obstructive hypertrophic cardiomyopathy for 10+ years. I successfully had surgical septal myectomy in Sep. 2012, I never had AF before the surgery, but I had three very short episodes of AF (each episode

Bruce_Wilkoff,_MD: Afib occurs in 30-40% of patients after heart surgery even if there was no afib prior to the surgery. Afib is more common in patients with HCM as well. Usually, if the Afib is only found after the surgery once the healing has completed (usually within three months) and the amiodarone is stopped the AFib does recur. However, Afib also occurs in people without HCM or heart surgery and as people get older it becomes quite common. Hopefully it will be a long time before you see AFib.

Arrhythmia – General questions

mfotey: What is the best way to determine if you have an arrhythmia?

Bruce_Wilkoff,_MD: An arrhythmia is characterized by the heart beating at an irregular rate, too fast, or too slow. Usually a patient will either feel palpitations or a racing of their heart rate. Sometimes the patient will feel faint or pass out. To see if an arrhythmia exists it's best to get an EKG during the symptoms. If the spells occur constantly then it’s easy to detect. But usually the symptoms are intermittent. We use a wearable EKG called a Holter monitor or an event monitor to take a recording at the moment of the symptoms. Many arrhythmias are of no significance but it is important to distinguish this from more serious situations.

40bigjohn: Hi, My name is John and I was first diagnosed with an arrhythmia after my hip replacement. Doctor thought it would disappear, since I never had it before. Now three years later still have it and no one can explain why it happened in the first place or why it doesn't go away. Also, have hemophilia B, which complicates the problem. Can you help with some ideas? Thank you.

Bryan_Baranowski,_MD: There are many different causes and mechanisms for arrhythmias. First step in management would be to capture the event on an arrhythmia event monitor - this would help us understand the cause and better determine the appropriate management. Some arrhythmias are benign and some are more malignant.

WRK: Sometimes my attacks are like this: rapid heart rate up to 165-175 then dropping to 45-65 , and then sometimes it only climbs to 90-110 but is slowing coming back down to 50-60, what does this mean?

Bryan_Baranowski,_MD: Rapid rises in heart rate are usually due to sudden onset of an abnormal heart rhythm and may be due to an extra electrical wire in the heart that short circuits the heart or the sudden onset of irritability in the heart. More gradual changes in the heart rate are due to your own natural pacemaker. To fully understand what you are feeling cardiac event monitoring is usually required.

GH: I'm trying to get in to see my EP, you guys are very busy. :) I was doing very well for the past five years and lately I have no energy at all, a little short of breath upon exertion and sometimes a weak feeling like I have to sit down if just standing for a bit, at the gym or cooking, etc. but not dizzy and no pain at all. My HR jumps from 70 to 120's with a short walk. Recent EKG, Echo and blood work are all fine, EF is 50% and has been for a few years now. I'm thinking it may just be an adjustment needed. Any ideas? Thank you in advance.

Bryan_Baranowski,_MD: I agree it probably is a simple medication adjustment however since your symptoms occur with exertion it may be worthwhile to undergo a stress test to see how your heart is functioning with exertion. We would be happy to see you - please call my office.

Anti-Arrhythmic Medications

invitations: I was prescribed flecainide for a high heart rate for two weeks now. Had severe reactions, coughing, feeling I couldn't breathe, had to sit up most of the night. 100mg twice a day, then cut to 50mgs twice a day, then 1/4 tablet twice a day. Did bring the heart rate down, but the symptoms still were with me. Now what?

Bryan_Baranowski,_MD: It does not appear that flecainide is going to be a viable medicine for you. There are multiple other medications that could be attempted. We would need to know more about you before this determination could be made. This would need to occur at a Clinic visit. Please let us know if you are interested in visiting here.

Reviewed: 03/14

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